Hadassah or Esther?

Hadassah's board of directors will not renew the contract of hospital CEO Shlomo Mor-Yosef. No one knows why. As owner, Hadassah Women's Zionist Organization of America can do what it sees as right, and confidentiality in sensitive discussions can be necessary. Meanwhile, however, a sense of unfairness and bewilderment has raised mistrust among hospital staff.

Hadassah is not a private company with trade secrets like Coca-Cola. As a public hospital serving over a half-million patients every year, largely through taxpayer funds, it bears greater accountability for transparency. Transparent governance is especially important in health care organizations from which the public demands accountability for quality and safety. People expect openness from nurses and physicians about performance and mistakes.

Creating a culture of transparency requires leading by example. By keeping silent, what message does the hospital's governing body send to staff? Leading a shift in strategy requires transparency, so that workers understand (even if they don't agree with) their leaders' decisions. In Hadassah's case, this might be particularly important because of the geographic and cultural gulf between the hospital and U.S.-based HWZOA.

Leaders who have successfully managed difficult change, such as Paul Levy at Harvard-affiliated Beth Israel Deaconess Medical Center, have made sure to keep communication open about their rationale for decisions. Transparency has characterized Hadassah under Mor-Yosef's leadership.

One of his first moves as CEO was to assign two professors to a new field of clinical quality and safety: Yoel Donchin, an anesthesiologist expert on human errors, and one of us (Brezis). "It is time we put a mirror in front of ourselves," Mor-Yosef said. "If we are good, let's show it. If not, let's improve."

This courageous motto enabled various initiatives that have contributed to patient welfare, such as using checklists before surgery, to reduce mistakes, and before insertion of a central line, to reduce infections. The challenge of balancing high-quality care with financial pressure demands more transparency and accountability about decision-making.

A substantial limitation to improving safety and results is, as in other industries, production pressure. Managers perceive that they are being measured by their ability to balance budgets. Messages to increase bed occupancy rates or reduce workforce are heard more frequently than discussions on how to prevent medication error or misdiagnosis.

The current remunerative system pays for quantity, not quality. In the face of competing incentives and difficult decisions, transparency helps to maintain shared understanding and trust.

HWZOA has a prestigious tradition of promoting public health, education and social action with remarkable generosity toward Israel. Disagreement about funding priorities, for instance if benefactors value social over medical targets, presents an opportunity for discussing social determinants of health - increasingly recognized as the best predictors of disease.

If benefactors prefer American over Israeli goals, that is also a legitimate dispute that will benefit from public discourse. Israel always benefits from financial help and it can benefit no less from exchange of culture, values and knowledge.

HWZOA was founded 98 years ago on Purim. It was named for Hadassah, the original name of Esther, the central heroine of Purim. Esther's name refers to secrecy, since hiding her nationality was pivotal in her winning stratagem to save her people.

The Talmud says, "Blessing is found only in what is hidden from the eye." Yet, at the right time, Esther revealed her secret.

In public policy too, secrecy can be key to transient success, but it will eventually undermine stakeholders' own interests. In health care, making difficult decisions with limited resources requires transparent governance. Hadassah is Esther but it should stay Hadassah.

Dr. Mayer Brezis is professor of medicine and director of the Center for Clinical Quality and Safety at Hadassah University Medical Center in Jerusalem.

Dr. Sara Singer is assistant professor of Health Care Management and Policy at the Harvard School of Public Health and assistant professor of medicine at Harvard Medical School/Mongan Institute for Health Policy in Boston.